The nurse asks a laboring client to lie on her left side. The appropriate rationale for this measure is to:

decrease the heart rate of the fetus

Aid the women while she pushes

prevent supine hypertension

prevent the client from falling out of bed

Answer and Explanation

The Correct Answer is C

A) Decrease the heart rate of the fetus:
Lying on the left side can sometimes help improve fetal oxygenation, especially if there is a concern about reduced blood flow from compression of the inferior vena cava, which can occur when the mother lies on her back. However, the primary rationale for this position is to prevent supine hypotension, not specifically to decrease fetal heart rate. In fact, side-lying can promote better oxygen exchange, which can indirectly benefit the fetal heart rate.

B) Aid the women while she pushes:
While a left-side lying position may offer comfort during labor and can help with uterine positioning, it is not specifically intended to aid in the pushing phase. Positions such as squatting or hands-and-knees are generally more helpful during the pushing phase because they can facilitate effective pushing and help the baby descend into the birth canal. The left-side position is more about circulation and preventing hypotension.

C) Prevent supine hypertension:
Supine hypotension occurs when the pregnant woman lies flat on her back, which can compress the inferior vena cava and reduce blood return to the heart. This leads to a drop in blood pressure and can compromise both maternal and fetal circulation. The left-side position is recommended because it helps to prevent this compression and allows optimal blood flow to both the mother and fetus, improving oxygenation and circulation.

D) Prevent the client from falling out of bed:
While lying on the left side may make the woman feel more stable, the primary reason for this position is to prevent supine hypotension, not to prevent her from falling out of bed. The nurse would ensure safety by using appropriate bed rails and monitoring, but the primary concern is supporting optimal circulation, not preventing falls.

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Correct Answer is B

Explanation

A) Right upper quadrant:
The right upper quadrant would not be the most appropriate place to auscultate the fetal heart rate in this scenario. In a vertex presentation with the fetal back on the left side, the best location for auscultation is typically along the fetal back, which is on the left side of the mother. The right upper quadrant would place you over the small parts of the fetus (limbs, hands, etc.), which generally would not be where the fetal heart rate is best heard.

B) Left upper quadrant:
The left upper quadrant is the most appropriate area to begin auscultation for this fetal heart rate (FHR) pattern. In this position, the fetal back is positioned towards the left side of the mother's abdomen, and the heart rate is typically heard most clearly over the back. The left upper quadrant would be over the fetal back, making it the best location to auscultate the FHR accurately.

C) Right lower quadrant:
The right lower quadrant would not be ideal for auscultating the fetal heart rate in this scenario. Since the fetal back is on the left side, the right lower quadrant would likely be over the fetal small parts (arms and legs), where the FHR would be harder to distinguish.

D) Left lower quadrant:
Although the left lower quadrant is on the left side of the mother, it's closer to the pelvic area and may be less effective for auscultating the fetal heart rate in this vertex presentation. It's more likely to be over the lower parts of the fetus, potentially interfering with accurate heart rate auscultation.

A. White blood cell count B. Blood clot size C. Uterine findings D. Lochia findings E. Calf findings F. Blood pressure

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

Client Finding Assessment:

White blood cell count (18,000/mm³)

Expected: An elevated white blood cell count is common postpartum due to the body's inflammatory response to delivery, especially within the first few days after birth. This level is within the typical postpartum range of 5,000 to 30,000/mm³.

Blood clot size (pea-sized)

Expected: Small blood clots are common during the early postpartum period. It is normal to see some small clots in the lochia as the uterus contracts and expels blood from the uterine lining.

Uterine findings (firm and midline, 1–2 cm below the umbilicus)

Expected: A firm, midline uterus with a descent of about 1–2 cm below the umbilicus is a normal finding during the early postpartum period. This indicates appropriate uterine involution.

Lochia findings (moderate to light amount, no odor, with clots)

Expected: Lochia rubra (red blood flow) is expected during the first few days postpartum, with moderate bleeding and the presence of small clots. The absence of foul odor suggests no infection, which is a positive sign.

Calf findings (one varicose vein visible on left calf)

Expected: It is common for women to have visible varicose veins during pregnancy due to increased blood volume and pressure on the veins. These may persist postpartum, and unless associated with pain or swelling, they do not typically require intervention.

Blood pressure (145/98 mm Hg)

Unexpected: Elevated blood pressure postpartum is concerning and could indicate postpartum hypertension or preeclampsia. This needs to be addressed and monitored closely as it can be a sign of a serious condition that requires further evaluation.

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The nurse asks a laboring client to lie on her left side. The appropriate rationale for this measure is to:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse on a postpartum caring for a client. Exhibits For each potential client finding, click to specify if the finding is expected or unexpected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

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